HomeMy WebLinkAbout0205 SCUDDER AVENUE - Health 205 SCUDDER LANE
HYANNIS
A = 289 079
i
J
Ili
`f e
TOWN OF BARNSTABLE
LOCATION 20S .SC SEWAGE # 7,60
VILLAGE m,4 v,/J ASSESSOR'S MAP & LOT 7-
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 {
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: OZ9/`''/
VARIANCE GRANTED: Yes No ��
�` �
g,
R�
o
__�. .---
��
/� 1 �
P�V �t
V� , • �l li
.a
No.�/ _� Fee l-o�.'�/
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:lot
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS
01ppYication for 30iopooal bpotem Congtrurtion Permit
Application for a Permit to Construct( . )Repair(d/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. a ps Owner's Name,Address and Tel.No. �Z •��_ 76
Assessor's Map/Parcel Art k, 'v1 �2C,O<L4k�,
�Y17 -® 7 yil
ACC S _Q_
Installer's Name,Address,and Tel.No. —7 7 F— Designer's Name,Address and Tel.No.
Q Cam C 0 a-co vv,.Va .
WC'
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets' Revision Date
Title
Size of Septic Tank Type of S.A.S.
I
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) '(IAQ�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the vironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss y s o of ealth.
Signed Date R®C
Application Approved by . Date r �O/
Application Disapproved for the following reasons
Permit No. Date Issued
V" / �1
/ � Fee
No.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
01ppYicatiou for Mioont 6potem eonztruction Permit
Application for a Permit to Construct( .)Repair(t/)Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. Q S;c ucQ ae,2 L.c,,,n @ Owner's Name,Address and Tel.No.! N. O Sr
Assessor's Map/Parcel T O\-N Y\ Co L C_0<Z A
Installer's Name,Address,and Tel.No. -7 7 S--—2 W Designer's Name,Address and Tel.No.
Q CC>..\ c o 3 s^0 w..41',
w es.-,- -A cw\Ap ,
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
-_.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ` `ct� \r N A
C:. T
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of theEiXvironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss s of Health.
Signed Date
Application Approved by Date 0 2 rZ01
Application Disapproved for the following reasons t
Permit No. y'" - ` t Date Issued
--------------------- ———— - —
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance f
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by CA+N cc O
at A CUSS 2/^, A 0-9-- has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. Fes`- dated G Z C
Installer P'z Cow`C O Designer
The issuance of this pefmit s 11 not be construed as a guarantee that the sys ill flu p ion _ designe..
11
Date �� �� Inspector ( r' .
r
—�" `7�p � -------------------------
No. Fee `3 yl�....-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLES MASSACHUSETTS
litpont *p,5tem y�otvaruction Perron
Permission is hereby anteOd Cstruct( ) epair(�)Up rade( )Abandon( )
System located at c' e A
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Constructs n mmust e completed within three years of the date of this tt.
Date: � Z�/ Gf Approved by G`
TOWN OF BARNSTABLE
`0:CATION 1 a SEWAGE #
;.,VILLAGE � ��" ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY / S0 -�'A-Q Jr`/
LEACHING FACELI TY: (type) -�-V-F=-o
(size) j V
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMTTDATE:— COMPLIANCE DATE:_ f• . 9 7
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private;Water Supply Well and Leaching Facility (If any wells exist
.60 site or within 200 feet of leaching facility)
Edge"of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by Feet
'Sl g"
N WIN OR
a
TOWN OF BARNSTABLE
LOCATION 20 .5c awkp,� SEWAGE #
VILLAGE CA.AA vU-4 '- ASSESSOR'S MAP &LOT
INSTALLER'S NAME & PHONE NO. A & B CANCO 175-1064
SEPTIC ,TANK CAPACITY ISM:
EA 0- :-FACILITY-if type)!
NO OF�BEDROOMS
.PRIVATE WELL OR'.PUBLIC'WATER
'.
:OR OWNER
R
AT'.-t-,p.E'RMIT ISSUED ::;'
z
DATE COMPLIANCE
1.
VARIANCE
kiXNCGRANT
j
-M�
ji
4.
3q4
'o-
f
r;
COMMONWEALTH OF MASS.ACHUSETTS ,{
,y EXECUTIVE OFFICE OF ENVIRONMENTAL AIRSe
DEPARTMENT OF ENVIRONMENTAL Tbb T IIWI/ir'r
l ` 16
ONE WINTER STREET. BOSTON. NIA 0_21
1104
FPT F
WILLl.4M F.WELD
UDY CO E
Govemo- ` Secretary
ARGEO PAUL CELLUCCI y DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
` '"C ERTIFIRCATION
40-5-
�� l/Property Addrec�(�.[ 1 v2_ Allct�,,,. Address of Owner:Date of Inspect /yam- (If different) 't� YYltcxc� (�J
Name of Inspector: :j2 t�r� - %\\%&& ra
t
1 am a DEP approved system inspector pursuant to Sections 15.. 40 of Title 5 (310 CMR 15.000) 1
Company Name: & //""
Mailing Address:—F-,a l��x �` �L�- /1.9S Qc���
Telephone Number: Tor— [t=42� /C= 2,=::)
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper tunction and
maintenance of on-site sewage disposal systems. The system: le�7 /�� /�/►
, t
Passes 137 4 ZQ
Conditionally Passes
_ 'seeds Furthe.r Evaluation By the Local Approving Authority
Fads
Inspector's Signature: jwl," 15— Date:
The Svstem Inspector shal' submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority. n� 'I
INSPECTION SUMMARY: Check A, B, C, or D: [ 55U& 06
A] SYSTEM PASSES: CQjIP c�(j ' 71 7
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
I failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
OEP on the World Wide Web http:lnvww magnet.state.ma.usldep
0 Printed on Recycied Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 13 7 Sct:; -0--
Owner:
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued)
fi
Sewagekbacup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s),or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Boa d of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT.FUNCTIONING IN A MANNER
., WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more'from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation.not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10 _
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3�S�t'�l c`" -2
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ N None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow- rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
N As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components. excluding the Soil Absorption System, have been located on the site.
_ . V,FIN The septic tank manholes were uncovered, opened. and the interior of the septic tank was inspected for condition of
baffles or tees, material o`construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Vl _ The facility owner land occupants, if different from owneri were provided with information on the proper maintenance of
"1 Sub-Surface Disposal System.
Ili Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: �3� SGv��if� ¢� . 7
Owner: "%t,X
Date of Inspection: 0s/2�1� �—
D] SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
_ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
_ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
�3 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flov;.
IJ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipes:.
Number of times pumped _.
Any portion of the Soil .Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
r
Any portion of a cesspool or privy is within a Zone I of a public well.
Any ponior, of a cesspool or privy is within 50 feet of a private water supply well.
N Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
colrform bacteria,-volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with-a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and,safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORh1
PART C
SYSTEM INFORMATION
Property Address: 1 3� �Lv��{.Q� ��,� u`��•
Owner: ' %ip-v- N Y
Date of Inspection:
�--
FLOW CONDITIONS
RESIDENTIAL:
Design flow. 330 e.p.d./bedroom for S.A.S.
Number of bedrooms:'_
Number of current residents: 0
Garbage g,::der (yes or no):�i is
Laundry corrected to system (yes or no): 14e-S
Seasonal use (yes or no): Nei
Water meter readings, if available (last two (2) year usage tgpd): pJI,*.
Sump Pump Ives or no): tJ
Last date of occupancv pUa2
COMMERCI.AUINDUSTRIAL:
Type of establishment.
Design fiov,: t alionsiday
Grease trap present: ryes or no,_
Industrial kkaste Holding Tank present: (yes or no.'._
Non-sanitan Aaste.discharged to the Titie S system: (yes or no'_
blater meter readings. if available
Last ilate of o cupancv
OTHER: ;Describe
Last date of occuoancv
GENERAL INFORMATION
PUMPING RECORDS and source of information:
1--g N rep o l fJij :4 a a,,� .-
System pumped as part of inspection: (yes or no! h11
If ,yes, volume pumped: eallons
Reason for pumping
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool `ewe.• N-,-a m op=�a1
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)_
(revised 04/25/97) page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �7 SG 11�441, 4::,cc.2
Owner: T—%NJ1
Date of Inspection:.9 cy��2
BUILDING SEWER: T
(Locate on site plan)
Depth below grader
Material of construction: _cast iron _40 PVC _other (explain)
Distance from private water supply well or suction li-t
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed b% Certificate of Compliance _(Yes'tvo.
Dimensions
Sludge depth
Distance from top of sludge to bottom of outlet tee or ba.41e.
Scum thickness:
Distance from top of scum to top of outlet tee or baffle.
Distance from bottom of scum to bosom of outlet tee or bane:
How dimensions were determined.
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP: 1V
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
DD SYSTEM INFORMATION (continued)
Property Address:
O%ner:'7—\tar, /
Date of Inspection:
TIGHT OR HOLDING TANK: N Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity- gallons
Design flow: gallons%da\
Alarm level. Alarm in working order_ Yes; _ No
Date of previous pumping
Comments:
(condition of inlet tee. condition o;alarm and float switches, etc.)
DISTRIBUTION BOV-0
(locate on site pian:
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan:
Pumps in working order: (Yes or Nol
Alarms in working order (Yes or Noi
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 30
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
e 00 SYSTEM INFORMATION (continued)
Property Address: 1 ' �U�r.[ct�.�. c��.� _ �t�/�. L4 u,y,
Owner: '{=tN.,C. l
Date of Inspection: d 5- AP
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; exca,afion not required. but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions.
overflow cesspool, number:
Alternative system
Name of Technologv:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, cgndi on f vegetation, etc.)
n-1-
O dc�2�\c�v.� P�T—•
CESSPOOLS:
(locate on site plan: t
Number and configuration:
Depth-top of liquid to inlet invert. 69
Depth of solids layer: a I 6 Is
Depth of scum layer: izn
Dimensions of cesspool:
Materials of construction:
Indication of groundwater
inflow (cesspool must be pumped as part of inspection) 1"]Cz,
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition f vegetation, etc.)o s
PRIVY: (�
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(reviaad 04/25/97) Page a of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/I SYSTEM INFORMATION (continued)
Property Address:
Owner: -V—%t rkl
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
i1e 1'�1
gao�w►,t�
B
C�Artw►t.,
t
N2_ 4o t
(revised 04/25/97) Page 9 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
1 SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of InspectiorV 5712
y l��
Depth to Groundwater!ZO Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board o; health
Check FEMA Maps
Check pumping records
Check local excavators. installers
Use LSGS Data
Describe in your ovm words how you established the High Groundwater Elevation. Must be completed)
tockZ.
SHwT 3�y ��r-pw's �SI4-�M � +e4txPc c_ v \ ,� o� "�b..�••� �.rL T■rw�. raT 2Ct
(revised 04/25/97) Pag• 10 of 10
v
TOWN OF BARNSTABLE
L&_'ATION -- 3:7 V c - SEWAGE # ZZ
• 17
VILLAGE b ASSESSOR'S MAP &LOT r'07
INSTALLER'S NAME&PHONE NO. 1V�zt7 ST ;�
SEPTIC TANK CAPACITY
LEACHING FACELITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER f6CC� �d tic�l
PERMTTDATE: 43=Y4_COMPLIANCE DATE: Z�
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
f�
°S�
t'
��.
_ d
0 ��
��
/ �
1 �
, � �
i
�.
J
:�
.r Y
No. — Fee
"^G
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Mizpa Y 6p.5tem �tCon.5truction Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or L o. � Owner's Name,Address and Tel.No.
3 1-37
Assessor's Map/Parcel 0-f C V',
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
R095.0�_ r`_i l ter
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow '37?.0 gallons per day. Calculated daily flow -3 C(c( gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank / SOD Type of S.A.S. L.T
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) zj=v—S_vPA t G�S ep1�L�t'�`• Qok
STd�
� �,.r1r
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and to place the system in operation until a Certifi-
cate of Compliance has t=ujs&ucAj2y this Board
Signed Date to / 3-7r"-'7
Application Approved by Date
Application Disapproved for Ad following reasons
Permit No. Date Issued
No. . Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE. MASSACHUSETTS
0(ppfication for air og r *pgtem Construction Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑.Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Fl37 Sc ��P„�awe.�
30 _,
Assessor's Map/Parcel
Inp(sstalleer''s Name,Address,and TO.No. Designer's Name,Address and Tel.No.
t'
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 33d gallons per day. Calculated daily flow 3 C4 gallons.
Plan Date Number of sheets Revision Date
Title P i`
Size of.Septic Tank /S60 Type of S.A.S. 6
Description of Soil
s
1
Nature of Repairs or Alterations(Answer when app icable) =t c-N yn,
o,t� - I i�• 4-, Cs., ni j 1 . LZ TI S (,���y` S/cttiQ Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and to place the system in operation until a Certifi-
cate.of Compliance has b�gjss„ " b this Board oLW
Signed Date d5 `/ 3`!`I-
Application Approved by- Date
Application Disapproved for t1W following reasons
Permit No. Date Issued
` ——————=— -——_— —— ———-————- ——-——
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance ,
THIS IS TO CERTIFY, that the QnIsiLe Sewage Disposal System Constructed(• )Repaired ( )Upgraded(1�
Abandoned( )by --7;"f-!n c, c
at 1 -7 r4.rp _ t4v De g 7 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. - P -dated /A- / 3 —9 7.
Installer Designer
'The issuance of this pe t shall not be construed as a guarantee that the system wil unction.as designed.
t
Date �� �� " Inspector
r
i
�� T `/ ---------------------------
No. Fee. (2 .'".
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
;Di!5po!5af *p.5tem Con.5truction Permit
Permission is hereby granted to Construct( )Repair( —iade( )Abandon
System located at 1�:7 _S r ,,Q d e-J A4,L-0
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
pProvided: Construction must be completed within three years of the date of this permit.
Date: w - % 7 Approved by
i
NOTICE:This Form is to be used for the Repair of Failed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL:
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS).`.
hereby certify that the application for disposal'works
construction permit signed by me dated U-1,3-9 , concerning the
property located at 13 7 AM-Q.-e meets:all of the
following criteria:
There are no wetlands within 300 feet of the proposed septic system
t There are no private wells within 150 feet of the proposed septic system
The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
ere is no increase in flow and/or change in use proposed
There are no variances requested or needed.
SIGNED : DATE: `3 `7
LICENSED SEPTIC 9YSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBgR
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
i
r
4 �i
0
i
!�
79 -
f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_. _... ._......oF .....N...... /.. .............................................
Appliratiuu -fur ui,ipuutt1 Murky Tonstrurtion Vrruiit
Application is hereby made for a Permit to Construct ( ) or Repair (L,-Y**a_n Individual Sewage Disposal
,,,(System at
............. 3 -------5-..........l.....� ...A m�.------------- ...........----------------------------------------------------------------------------------
L c i n:Address or Lo No.
----..1+!► ., i.!� ................. 1 -S�. c�.c�l. .r .._. `' ��y� �N.r�.----
wner , A dress
13 • �vt2 o � A�ZWve��---
. ---------------•- ------------.---...---•--------------. -------•-••-•...
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms--- .....................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q Other fixtures
W Design Flow..................
..................... per person per day. Total daily flow............................................gallons.
P4 Septic Tank—Liquid capacity------------gallons Length................ Width_.............. Diameter----------------- Depth_.-_----._._.
xDisposal Trench—No. .................... Width-------------------- Total Length------------------.. Total leaching area.._.-..-__-_.-___-_-sq. ft.
Seepage Pit No.)__O UM_ ...... Diameter..... ..._....... Depth below inlet_.. ...........Total leaching area-----.-.----------sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by---------------- •----•-•-----------------------------------••---•-•------ Date-------------------------- ------------
,.� Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water...---.-___._-__.-._-.-.
fX-4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__.__.-.--_-----------.-
P4 -•----------•-•------------..............................................................................................................................
ODescription of Soil..................................................................................................................------------------------------------------------------
x
W
-- --------------
V Nature of Repai s or Alterations'-Answer when applicable.�-.`-�_��'----Ib .1....�!__1.-__-_�TG%�!e�................
---------L I--�"---- ------------.0-u� .mod? 1Olx............................................................................................--------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witli
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board` f health.
Signe -----/--------------- 1! /SJ ��
------------------------------------ ------ ------- ------ ------
` Da e
Application Approved By.............. 1`----------------------------------------------------------------------- � �`�� --7 2
Date
Application Disapproved for the (011owing reasons:---------------•----------.-_------------------•-------•--•---•-•-•--------••-•-------------Da.t.e--------------
---------------------------------------------------------•----------•--•-•------•-•------- --•----------------•--• --------------------• •------••--------•---•------------•--•-------•---•-----------
Date
Permit No / Issued. .............................. ..........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ZA;_ _ . _. - ------- OF:. .. ...`a. ..14 ... ...........................................
Appliratinn -fur Biipuiittl Workfi Tonfitrnrtiun Vrrniit
Application is hereby made for a Permit to Construct ( ) or Repair �an Individual Sewage,Disposal
System at
s
..................... �' ..✓� s y
.................. ..y.....,.,.,......•y---•---....-----•--•--•........L..._..N..o......•...-.......r
•. .................
oc tAon-Address r
.............4r ?.1............f #
tt i Qwner x , Address
- -
Installer Address
Q Type of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms--._....�..�`�''.............................Expansion Attic ( ) Garbage Grinder ( )
W
a, Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures
W
Design Flow.................�-_S__._______--_-____gallons per person per day. Total daily flow...___._.____.___._.___....._.._...........gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter------.......... Depth----------------
x Disposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area.-------------------sq. ft.
Seepage Pit NoJ.P °°K:-P_4______- Diameter..... Depth below inlet....."........... Total leaching area------- ----------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by........................................................... ... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-..___.._-__-_-_-_--.
Test Pit No. 2----------------minutes per inch Depth of Test Pit---::-___._._______- Depth to ground water__._.._-______-_._-----
ODescription of Soil------ .---•-•-----•.........-•-------•-•-•--•-••-----•---•-•-----•-•-••-----•--------------•-•-•-•--•---•••-------•-----...----------------------------------------
x
.................•-----------
w
�xj Nature of Repairs or Alterations Answer when applicable ._'.f `" C� n ' k a VVI '_.................................
......_... yXj ^.?_!Cl< �r .............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board pf health.
Signed7
Daie
� - 11. j 7 7
Application Approved By------------- • ----------------------------.....--------------- --------------
-------- Date
Application Disapproved'for t7ie following reasons:---------------------------------•-.--.-_.------------------------------.-_--------_--------•-----•-------------
•.........--•-------------••----•-•-•-------------------------••-•-......------......--•-----•----------------------------•-------------------------------------------------------....................
ate
PermitNo........4�•• -----_-----------•---------- Issued........................................................
Date
TI-JE.COMMONWEALTH OF MASSACHUSETTS le;o 6.
�r BOARD OF HEALTH ,
.........../...'±. ! "............0F...... !4.f�.lT
Y.` �rrtifir tr of QT mplittnrr
y
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (`+ )
bY-------- ........... ..•--te ..�... -. _
Installer ; .
�7
at................'j' '
has been installed in accordance with the provisions of Article XI of The State Sanitary Co&� desc"t6d in the
application for Disposal Worlcs Construction PermittNo 7wr� L �^............... dated.....e_2Xn_! ---7 ?...........
THE ISSUANCE OF THISI CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE___ ,.
Inspector
THE COX9 ONWEALTH OF MASSACHUSETTS
BOARD OF H-t,*LTH
................ a .�r........ . OF....r,� �t . .................................
No......................... FEE
Bispatial Morkii Tontitrnrtiun Vrrmit
Permission is hereby granted---------.....'' o._1ler o&_7�:.....a&/(,
-•---------------•---------•----•.........-----------...--•...._------•-•-••......•.
to Construct ( ) or Repair O an Individual Sewage Disposal System
at No.............. y--!•'-•-. &�_,c '� ----..A.EiG.............!,/'f Ijrtc l4 f ----•--•-•--•-------------------------------•------...-•-----------•----
Street
as shown on the application for Dl posal Works Construction Permit No _A�_._'�------ Dated.......l:!Z 7 7 -
----- -------------------- ...............
Boa;4, Heath
DATE.------.... ------ ..�. .............
_._......_ I ....................
--- = -»..,
Ls� s" i,ff{dr 4
FORM 1255 HOBBS & WARR,EN.,.INC.. PUBLISHERS _
LO-CATI SEWAGE PERMIT
VILLAGE
/ ,3 7_
INSTA LLER'S NAME & ADDRESS
B U It D E R OR OWNER r:
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ( �� , `
,�
ttr
i `
�e qq `�� `v
w
�^o c wn i
,L. ' U
�t 7
:� �:
°`
1
1
� �